Foreword

NaDIA 2019 shows that, since the audit began in 2010, the very impressive improvements in many aspects of inpatient diabetes care have continued, including reductions in medication errors, severe hypoglycaemia and hospital-acquired diabetic foot lesions. However, the occurrence of some important and life-threatening harms remain unchanged:

- Severe hypoglycaemic episodes in inpatients with type 1 diabetes
- Hospital-acquired diabetic ketoacidosis (DKA)
- Hospital-acquired hyperosmolar hyperglycaemic state (HHS)

DKA and HHS are preventable and should not occur during a hospital admission. In this respect it is of interest that all medication errors have reduced with the exception of one, the failure to increase insulin when the capillary blood glucose (CBG) is persistently above 11 mmol/L, suggesting that focusing on staff training in hyperglycaemic management and insulin dose adjustment may reduce these life threatening harms.

It is important to recognise the hard work of diabetes teams and the almost one hundred per cent participation in this annual audit, without which we may not have realised these improvements nor identified where we need to redouble our efforts. No other healthcare service in the world has such comprehensive national data to evidence and direct change in inpatient care; a unique achievement for which we should be proud.

Gerry Rayman, Clinical Lead for the National Diabetes Inpatient Audit, Diabetes UK lead for Inpatient Diabetes, GIRFT Co-lead

Partha Kar, National Specialty Lead, Diabetes, NHS England, GIRFT co-lead

Notes: 1. The concentration of glucose in the blood. 2. GIRFT = Getting It Right First Time Deep-dive reports are available for each of the numbered chapters, plus the following topics: foot disease management, blood glucose monitoring, use of insulin infusions and a separate report on hypoglycaemic episodes.

The deep-dive reports contain additional background, analysis and clinical commentary. See slide 9 for further information. Executive summary: Improvements in diabetes inpatient care

188 out of 193 hospital sites known to be eligible for NaDIA took part in the 2019 audit (97 per cent)(^1). The **commitment** and **hard work** by hospital teams to collect data and their dedication to using the analysed results to alter their practice has delivered some very encouraging **improvements**. This has been achieved with the help of an appreciable increase in staffing levels since NaDIA 2017, treating a consistently high proportion of people in hospital who have diabetes - 18 per cent in NaDIA 2019.

**In the face of this heavy workload teams have:**

- **Delivered more personal care** to inpatients with diabetes – 75 per cent of those surveyed in 2019 were **seen by the diabetes team** where appropriate(^2) compared to only 54 per cent in 2010.
- Reduced the proportion of inpatient drug charts found to contain **medication errors** by 15 percentage points since 2010 (from 45 to 30 per cent).
- Reduced **severe hypoglycaemic** episodes from 12 per cent of inpatients during the last 7 days of their hospital stay in 2010 to 7 per cent in 2019.
- Reduced the need for **injectable rescue treatment** for severe hypoglycaemia – from 2.4 per cent of inpatients during the last 7 days of their hospital stay in 2010 to 1.4 per cent in 2019.
- Reduced patients developing **foot ulcers** at any point during their hospital stay – from 2.2 per cent of inpatients audited in 2010 to 1.1 per cent in 2019.

**Notes:** 1. Eligibility inferred from past NaDIA participation. 2. Based on the ‘Think Glucose Criteria’. See **Glossary: Referral to the diabetes team**. Executive summary: Areas where further improvement needed

Despite the significant and important improvements documented in slide 4, NaDIA also demonstrates that there is still considerable scope for further improvements.

On the day of the audit in 2019, NaDIA found high levels of:

- **Medication errors** – almost 1 in 3 of the inpatient drug charts surveyed had at least one medication error.
- **Insulin errors** – two fifths of inpatient drug charts for insulin-treated inpatients had one or more insulin error.
- Hospital-acquired **diabetic ketoacidosis** (DKA): on the day of the audit, 3.6 per cent of inpatients with type 1 diabetes had developed in-hospital DKA at any point during their hospital stay.
- **Capillary blood glucose**¹ (CBG) levels not being recorded at all recommended stages of the perioperative pathway².

All of these findings clearly demonstrate the benefit of NaDIA in identifying areas on which to focus service improvements, and in driving and tracking change.

NaDIA team

Notes: 1. The concentration of glucose in the blood. 2. At sign-in and sign-out stages of the surgical safety checklist, during surgery, in theatre recovery, on arrival on the ward. Executive summary: Areas where action is recommended

**Recommendation 1:** The MDiT(^1) should meet regularly to discuss day-to-day errors and safety issues, and report to a quarterly trust-level diabetes safety board. All hospital-acquired life-threatening episodes of hypoglycaemia, DKA and HHS should be recorded as serious incidents, submitted to NaDIA-Harms and root cause analysis undertaken.

**Recommendation 6:** All trusts should have and promote a self-management policy, which supports patients who want to self-manage their diabetes to safely do so while in hospital, as clinically appropriate and in line with wider NHS England and NHS Improvement policies on inpatient self-management.

**Recommendation 2:** Training should be provided for every healthcare professional who dispenses, prescribes and/or administers insulin, appropriate to their level of responsibility, including an assessment of competency. Electronic records and prescribing should be implemented in support.

**Recommendation 3:** All trusts should have a dedicated multi-disciplinary team of specialist diabetes inpatient practitioners as indicated in the NHS Long Term Plan. Trusts should work towards providing base level specialist diabetes cover at weekends where this does not exist.

**Recommendation 4:** All trusts should have a robust system to identify all people with diabetes on admission to hospital, including emergencies and elective and non-elective surgery, and a triage system to identify those at risk and rapidly refer them to the diabetes team. This should be an electronic system, integrated with web-linked blood glucose meters which provide an alert system for staff when any out-of-range reading is recorded.

**Recommendation 5:** All hospital trusts should have clear, audited perioperative pathways from pre-assessment through to discharge. These should be broadly in line with NCEPOD recommendations.

**Notes:** 1. MDiT = Multi-disciplinary inpatient team. Introduction: Overview

- The National Diabetes Inpatient Audit (NaDIA) measures on one day the quality of diabetes care provided to all people with diabetes while they are admitted to hospital whatever the cause, and aims to support quality improvement.

- Data is collected and submitted by hospital staff in England. Wales did not participate in NaDIA 2019. Following a change in legal basis(^1) in England to a Direction from NHS England for NHS Digital to process data, the Welsh Assembly government have been pursuing a request as a legal basis, but this was not completed in time for Welsh hospitals to participate.

- The NaDIA audit is part of the National Diabetes Audit (NDA) programme within the National Clinical Audit and Patient Outcomes Programme (NCAPOP), commissioned by the Healthcare Quality Improvement Partnership (HQIP).

This is the full report. Deep-dive reports are available for individual chapters, including four additional chapters. Local reports and supporting data are also published.

Notes: 1. EU General Data Protection Regulation. Article 6: Lawfulness of processing: https://www.privacy-regulation.eu/en/article-6-lawfulness-of-processing-GDPR.htm. Introduction: Audit questions

The audit sets out to measure the quality of diabetes care provided to people with diabetes while they are admitted to hospital, by answering the following questions:

• Did diabetes management minimise the risk of avoidable complications? • Did harm result from the inpatient stay? • Was patient experience of the inpatient stay favourable? • Has the quality of care and patient feedback changed since NaDIA 2010, 2011, 2012, 2013, 2015, 2016 and 2017(^1)?

The report will be of interest to the public, especially to people with diabetes. Health planners and policy makers, as well as acute NHS trusts, Clinical Commissioning Groups (CCGs), Local Health Boards (LHBs), Sustainability and Transformation Partnerships (STPs), Clinical Networks (CNs; formerly Strategic Clinical Networks or SCNs) and other providers and commissioners of specialist diabetes services will also make use of the information in this report.

Notes:

1. Wales did not participate in NaDIA 2019 (see slide 7), so data from earlier years has been re-analysed to include English hospital sites only. To help ensure that tables and charts remain uncluttered as the audit duration increases, NaDIA 2011, 2012 and 2016 have been excluded from most tables and charts. There was no audit collection or report in 2014, so 2014 data is not available. Wales did not participate in NaDIA 2010.

# Introduction: Supporting data

NaDIA publishes a wealth of supporting data in addition to this report:

| Deep-dive reports | Local reports | |-------------------|---------------| | 0 Key messages | Hospital Level Analysis 2010-19 | A wide range of NaDIA outputs at hospital site-level from 2010 to 2019 | | 1 Participation and prevalence | Hospital Characteristics Report 2019 | All 2019 Hospital Characteristics results at hospital site-level, compared to national data | | 2 Inpatient harms | Hospital Characteristics Responses 2010-19 | Time series of all comparable Hospital Characteristics results at hospital site-level from 2010 to 2019 | | 3 Medication errors | Main Areas For Improvement Report 2015-19 | Main areas for improvement at hospital site-level identified by inpatients with diabetes 2015 to 2019 | | 4 Care improvement initiatives | | | | 5 Staffing levels | | | | 6 Access to the diabetes team | | | | 7 Surgical care | | | | 8 Patient experience | | | | 9 **Foot disease management** | | | | 10 **Blood glucose monitoring** | | | | 11 **Use of insulin infusions** | | | | 12 **Hypoglycaemic episodes** | | |

**Bold** = Not covered in the [main report](#) (this document). Introduction: Terminology

Main abbreviations

| Acronym | Description | |---------|-------------| | DISN | diabetes inpatient specialist nurse | | DKA | diabetic ketoacidosis | | DSN/DISN| diabetes (inpatient) specialist nurse | | HHS | hyperosmolar hyperglycaemic state | | MDiT/MDFT| multi-disciplinary (inpatient/foot care) team | | NICE | National Institute for Health and Care Excellence | | OA-DA | oral anti-diabetic agent |

The above acronyms will not always be footnoted in the report. For an extended list of abbreviations, see Glossary: Acronyms.

Patient harms and medication errors

The audit looks at the proportion of inpatients that experience the following patient harms during their hospital stay:

- Severe hypoglycaemic episodes in the last 7 days
- Hypoglycaemic episodes requiring injectable rescue treatment in the last 7 days
- Hospital-acquired DKA and HHS
- Hospital-acquired diabetic foot lesions

Medication errors are broken down into two main sub-types:

- Prescription errors
- Glucose management errors

A further sub-category of insulin errors covers prescription and glucose management errors relating to insulin.

A single inpatient drug chart may contain multiple medication errors and a single inpatient may experience multiple patient harms.

For further information, see Glossary: Patient harms and Medication errors: Definitions.

Cohorts used in the report

Wales did not participate in NaDIA 2019, so NaDIA data from earlier years has been re-analysed to include English hospitals only.

Outputs are often split by audit year (see right) and/or diabetes type.

Inpatients with type 1 diabetes are reported as a single group. Inpatients with type 2 diabetes are grouped into three sub-categories based on their treatment type:

- Type 2 (insulin)
- Type 2 (non insulin)
- Type 2 (diet only)

For further information, see Glossary: Diabetes type and Diabetes treatments.

1. Key messages: Participation and prevalence

Findings

- 188 out of 193 hospital sites known to be eligible for NaDIA took part in the 2019 audit (97 per cent)(^1).
- Bedside data on 15,479 inpatients in England was submitted, almost 600 more inpatients than NaDIA 2017(^2).
- Over half of inpatients returned a Patient Experience questionnaire (56 per cent).
- Around 1 in 6 hospital beds are occupied by a person with diabetes (18 per cent, an increase from 14 per cent in 2010). 1 in 15 of the total population have diabetes (7 per cent).
- In 11 hospital sites, over one quarter of inpatients have diabetes (25 to 31 per cent).

Notes: 1. Eligibility inferred from past NaDIA participation. 2. Wales did not participate in NaDIA 2019, so 2017 figures have been recalculated to cover England only. 2. Key messages: Inpatient harms

Findings

- The proportion of audited inpatients that developed a diabetic foot ulcer or needed a hypoglycaemic rescue has **reduced** since 2010, though there has been **no reduction** since 2017.
- Although the proportion of inpatients experiencing severe hypoglycaemia has **dropped** overall, there has been **no reduction** amongst inpatients with type 1 diabetes since 2010.
- And there has been **no significant change** in inpatients acquiring diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic state (HHS) since data collection began.

**Recommendation 1:** The MDiT should meet regularly to discuss day-to-day errors and safety issues, and report to a quarterly trust-level diabetes safety board. All hospital-acquired life-threatening episodes of hypoglycaemia, DKA and HHS should be recorded as **serious incidents**, submitted to **NaDIA-Harms** and root cause analysis undertaken. Inpatient harms: Severe hypoglycaemia

Chart 2.1: Inpatients having one or more severe hypoglycaemic episode(^1) in the last 7 days of their hospital stay: by diabetes type, England, 2010-19

| Diabetes type | Significant difference ((p < 0.05)) | |------------------------|----------------------------------------| | | 2010 to 2019 | 2017 to 2019 | | Type 1 | Static | Static | | Type 2 (insulin) | Down ▼ | Static | | Type 2 (non insulin) | Down ▼ | Static | | Type 2 (diet only) | Down ▼ | Static | | Total | Down ▼ | Static |

Notes: * = statistically significant at the 0.05 level (vs. current audit year). (n) = not statistically significant (vs. current audit year).

1. Severe hypoglycaemic episode = \<3.0mmol/L.

Findings

- Severe hypoglycaemic episodes have **decreased** for all type 2 groups since 2010, though proportions have remained static since 2017.

- On the audit day in 2019, more than **1 in 4** inpatients with type 1 diabetes had experienced at least one severe hypoglycaemic episode in the last 7 days of their hospital stay. There has been **no significant reduction** in severe hypoglycaemia episodes in patients with type 1 diabetes. Findings

- On the audit day in 2019, **1 in 70** inpatients had required hypoglycaemic rescue during the last 7 days of their hospital stay.

- Hypoglycaemic rescue has **decreased** since 2010, though not since 2017.

Notes:

- = statistically significant at the 0.05 level (vs. current audit year). ( n ) = not statistically significant (vs. current audit year).

1. See [Glossary: Patient harms](#). Inpatient harms: DKA and HHS

Findings

There has been no significant change in either DKA or HHS since data collection began.

On the audit day in 2019:

- **3.6 per cent** of inpatients with type 1 diabetes had developed DKA at any point during their hospital stay; and
- **0.2 per cent** of inpatients with type 2 diabetes had developed HHS at any point during their hospital stay.

Notes: * = statistically significant at the 0.05 level (vs. current audit year). n = not statistically significant (vs. current audit year).

1. See Glossary: Patient harms. Findings

- On the audit day in 2019, around 1 in 90 inpatients with diabetes had developed a foot ulcer at any point during their hospital stay.
- The proportion of inpatients that had developed diabetic foot ulcers during their admission has reduced since 2010 (from 2.2 per cent to 1.1 per cent), but has not changed since 2017.

Notes: * = statistically significant at the 0.05 level (vs. current audit year). n = not statistically significant (vs. current audit year).

1. See Glossary: Patient harms.
2. Key messages: Medication errors

Findings

- Almost **one third** of inpatient drug charts audited in 2019 had at least one medication error (30 per cent). This has **reduced** from 45 per cent in 2010.
- **18 per cent** of inpatient drug charts had one or more insulin error during their hospital stay, which is an **improvement** from 26 per cent in 2010.
- The proportion of inpatient drug charts with at least one prescription error has **decreased** since 2017 (from 19 to 17 per cent), although the proportion of glucose management and insulin errors has remained **static** over this period.

Clinical comment: Despite improvements in recent years, the proportion of inpatient drug charts with medication errors is still too high, even in hospital sites that have adopted health technologies (see slides 22 and 23). Findings

- In the 2019 audit, **3 out of 10** inpatient drug charts had at least one medication error (30 per cent).
- The proportion of inpatient drug charts having medication errors has **decreased** by 14 percentage points since 2010.

Notes: * = statistically significant at the 0.05 level (vs. current audit year). ( n ) = not statistically significant (vs. current audit year).

1. See Medication errors: Definitions for explanation of error types. Findings

- In the 2019 audit, **4 out of 10** drug charts for insulin-treated inpatients had at least one medication error (40 per cent).
- The proportion of inpatient drug charts with medication errors has **reduced** for all diabetes types since 2010, but has **not changed** since 2017.

Notes: * = statistically significant at the 0.05 level (vs. current audit year). n = not statistically significant (vs. current audit year).

1. See Medication errors: Definitions for explanation of error types.
2. Key messages: Care improvement initiatives

Findings

- An **increasing** proportion of hospital sites are now fully-utilising electronic prescribing (EP) and electronic patient record (EPR) systems, and remote blood glucose monitoring (BGM).
- Inpatient drug charts are **less likely** to contain medication errors if EPR or EP are used.

**Recommendation 2:** Training should be provided for every healthcare professional who dispenses, prescribes and/or administers insulin, appropriate to their level of responsibility, including an assessment of competency. Electronic records and prescribing should be implemented in support.

**Clinical comment:** NaDIA has found that 1 in 10 hospitals manage to print carbohydrate content on their hospital menus (9.4 per cent) which is very helpful to inpatients with diabetes. Findings

The proportion of hospital sites fully-utilising EP has increased since 2017, from 32 to 45 per cent.

The proportion of hospital sites fully or partially utilising EPR has increased since 2017, from 71 to 82 per cent. Care improvement initiatives: EPR and medication errors

Chart 4.3: Inpatient drug charts having one or more medication error(^1) in the last 7 days of their hospital stay: by electronic patient record (EPR) usage(^2), England, 2019

| Error type | Significant difference ((p < 0.05)) | EPR used | EPR not used | |-----------------------------|----------------------------------------|----------|--------------| | Medication error | Less likely | More likely | | Prescription error | Less likely | More likely | | Glucose management error | No difference | No difference | | Insulin error | Less likely | More likely |

Finding

- Inpatient drug charts are **less likely** to contain medication, prescription and insulin errors if EPR is used.

Notes: * = statistically significant at the 0.05 level (EPR used vs. EPR not used in audit year). (n) = not statistically significant (EPR used vs. EPR not used in audit year). 1. Medication error = any prescription or glucose management error. See Medication errors: Definitions for explanation of error types. 2. See Glossary: Healthcare technologies for information on EPR. Care improvement initiatives: EP and medication errors

Chart 4.4: Inpatient drug charts having one or more medication error(^1) in the last 7 days of their hospital stay: by electronic prescribing (EP) usage(^2), England, 2019

| Error type | Significant difference ((p < 0.05)) | |-----------------------------|----------------------------------------| | | EPR used | EPR not used | | Medication error | Less likely | More likely | | Prescription error | Less likely | More likely | | Glucose management error | Less likely | More likely | | Insulin error | Less likely | More likely |

Finding

- Inpatient drug charts are **less likely** to contain all types of medication error if EP is used.

Notes: * = statistically significant at the 0.05 level (EP used vs. EP not used in audit year). n = not statistically significant (EP used vs. EP not used in audit year). 1. Medication error = any prescription or glucose management error. See Medication errors: Definitions for explanation of error types. 2. See Glossary: Healthcare technologies for information on EP. Care improvement initiatives: Remote BGM

Chart 4.5: Percentage of hospital sites using remote blood glucose monitoring (BGM), England, 2013-19

Findings

- The proportion of hospital sites fully-utilising remote BGM has increased by 17 percentage points since 2017 and has more than doubled since 2013 (from 35 to 71 per cent).
- However almost 1 in 5 hospital sites do not utilise remote BGM (18 per cent).

Notes: 1. Diabetes UK, Making hospitals safe for people with diabetes, 2018 Care improvement initiatives: M&M

Chart 4.6: Percentage of hospital sites holding diabetes mortality and morbidity (M&M) meetings(^1), England, 2015-19

Findings

- The proportion of hospital sites having diabetes M&M meetings has **increased** since 2017.
- Almost **two-thirds** of hospital sites hold diabetes M&M meetings.
- **40 hospital sites** fully-utilise EPR, EP and remote BGM.

Table 4.1: Number of hospital sites that fully utilise electronic patient record (EPR), electronic prescribing (EP) and remote blood glucose monitoring (BGM), England, 2013-19

| Audit year | Hospital sites having EPR, EP and remote BGM | |------------|---------------------------------------------| | 2013 | 5 | | 2015 | 14 Increase | | 2017 | 24 Increase | | 2019 | 40 Increase |

Notes: 1. If the hospital site does not hold a diabetes M&M meeting, they may hold a general M&M meeting where diabetes is discussed. This information has not been collected for 2019. 5. Key messages: Staffing levels

Findings

- Staffing levels for almost all professions have increased for inpatients with diabetes since 2015 and 2017.
- However, improvements are sometimes from a low starting point (e.g. less than 1 minute per inpatient per day of podiatrist and dietitian time in 2015) and diabetes specialist pharmacist hours have actually decreased.
- Almost one fifth of hospital sites report no dedicated diabetes inpatient specialist nurses (DISNs) (18 per cent).
- Inpatient dietetic provision, although improved, is still too low (only 35 per cent of hospital sites).

Clinical comment

Despite recent positive increases in staffing levels, NaDIA has found that staffing deficiencies remain, with access to specialist diabetes dietitians and pharmacists a particular problem. This is especially important in the context of continually rising patient numbers.

Recommendation 3: All trusts should have a dedicated multi-disciplinary team of specialist diabetes inpatient practitioners as indicated in the NHS Long Term Plan. Trusts should work towards providing base level specialist diabetes cover at weekends where this does not exist.

### Table 5.1: Average staffing for care of inpatients with diabetes(^1), England, 2015-19

| Profession | Hours per week of inpatient care per inpatient with diabetes | |------------------------------------------------|-------------------------------------------------------------| | | 2015 | 2017 | 2019 | | Diabetes inpatient specialist nurse (DISN) | 0.51 | 0.63 | 0.79 | | Diabetes specialist nurse (DSN) | 0.17 | 0.22 | 0.39 | | Any diabetes specialist nurse (DISN and DSN) | 0.68 | 0.85 | 1.18 | | Diabetes consultant | 0.19 | 0.29 | 0.38 | | Podiatrist | 0.11 | 0.16 | 0.26 | | Specialist diabetes dietitian | 0.03 | 0.04 | 0.07 | | Non-specialist dietitian | 0.07 | 0.05 | 0.14 | | Any dietitian | 0.10 | 0.09 | 0.22 | | Diabetes specialist pharmacist | 0.03 | 0.07 | 0.05 |

### Findings

At national level, staffing levels for almost all professions have **increased** for inpatients with diabetes since 2015 and 2017:

- DISN hours per inpatient have **increased** from 0.63 in 2017 to 0.79 in 2019.
- Diabetes Consultant hours have **increased** from 0.29 in 2017 to 0.79.
- Podiatrist hours have **increased** from 0.16 in 2017 to 0.26.
- Dietitian hours have **increased** from 0.09 in 2017 to 0.22.

However, some of the increases are from a **low starting point** (e.g. less than 1 minute per inpatient per day of podiatrist and dietitian time in 2015).

And diabetes specialist pharmacist hours have **decreased** from 0.07 in 2017 to 0.05 in 2019.

______________________________________________________________________

**Notes:**

1. The stated figures are derived from the total number of Bedside Audit forms divided by the total number of hours of inpatient care per week. The NaDIA team acknowledge the difficulty of estimating staff hours. Caution is therefore advised when interpreting staffing levels, particularly at hospital site level.

### Table 5.2: Changes in staffing of hospital sites, England, 2010-19

| Percentage of hospital sites with: | 2010 | 2013 | 2015 | 2017 | 2019 | |-----------------------------------|------|------|------|------|------| | • no diabetes inpatient specialist nurse (DISNs)¹ | 31.5 | 30.2 | 29.3 | 25.9 | 18.2 | | • no specialist inpatient dietetic provision for inpatients with diabetes | 67.3 | 71.4 | 71.8 | 72.0 | 64.6 | | • no inpatient podiatry service for inpatients with diabetes | 26.8 | 33.3 | 25.5 | 32.3 | 18.2 | | • no inpatient specialist pharmacy service for inpatients with diabetes | – | 88.0 | 83.0 | 75.7 | 74.0 |

### Findings

- The proportion of hospital sites with no DISNs has **dropped** by 8 percentage points since 2017.
- However, more than a **sixth** of hospital sites have no DISNs (18 per cent). **Two-thirds** of these hospital sites also had no DISNs in 2017².

______________________________________________________________________

**Notes:**

1. 33 hospital sites had no DISNs in 2019. 21 of the 33 also had no DISNs in the 2017 audit, along with a further 28 hospital sites.
2. NHS England, *NHS Long Term Plan*, 2019.
3. Key messages: Access to the diabetes team

Findings

- The proportion of inpatients with diabetes seen by the diabetes team where appropriate(^1) has increased since 2010 (from 54 to 75 per cent).
- A higher proportion are seen by the diabetes team(^1) when 7 day diabetes inpatient specialist nurse (DISN) cover is provided (78 per cent compared to 72 per cent).

Notes: 1. Based on the ‘Think Glucose Criteria’ criteria. See Glossary: Referral to the diabetes team.

Clinical comment: GIRFT has found that in some hospitals, staff only become aware that a patient had diabetes when a problem occurs, which can result in serious and life-threatening harms. However, NaDIA has found that only 36 per cent of hospital sites have an electronic system to identify and notify the diabetes team of all people with diabetes on admission.

Diabetes ID system?

| Yes | No | |-----|----| | 36% | 64% |

Recommendation 4: All trusts should have a robust system to identify all people with diabetes on admission to hospital, including emergencies and elective and non-elective surgery, and a triage system to identify those at risk and rapidly refer them to the diabetes team. This should be an electronic system, integrated with web-linked blood glucose meters which provide an alert system for staff when any out-of-range reading is recorded. Access to the diabetes team: Results

Based on the ‘Think Glucose Criteria’(^1), on the audit day it was appropriate for 41 per cent of inpatients to have been referred to the diabetes team, six percentage points lower than in 2011.

Chart 6.1: Percentage of inpatients seen by the diabetes team where it was deemed appropriate(^1): by diabetes type, England, 2010-19

| Audit year | Type 1 | Type 2 (insulin) | Type 2 (non insulin) | Type 2 (diet only) | Total | |------------|--------|------------------|----------------------|-------------------|-------| | 2010 | 65.1 | 77.2 | 78.7 | 79.7 | 86.2 | | 2013 | 62.3 | 67.2 | 72.9 | 75.4 | 78.0 | | 2015 | 44.2 | 53.9 | 59.3 | 66.6 | 65.7 | | 2017 | 38.0 | 45.2 | 58.0 | 66.4 | 63.2 | | 2019 | 54.4 | 62.7 | 68.0 | 72.5 | 74.7 |

Source: NHS Digital

Comparison Significant difference (p \<0.05)

| Comparison | Type 1 | Type 2 (insulin) | Type 2 (non insulin) | Type 2 (diet only) | Total | |------------|--------|------------------|----------------------|-------------------|-------| | 2010 to 2019 | Up ▲ | Up ▲ | Up ▲ | Up ▲ | Up ▲ | | 2017 to 2019 | Up ▲ | Up ▲ | No change – | No change – | Up ▲ |

Notes: * = statistically significant at the 0.05 level (vs. current audit year). (n) = not statistically significant (vs. current audit year).

1. Based on the ‘Think Glucose Criteria’. See Glossary: Referral to the diabetes team.

Findings

More inpatients are being seen by the diabetes team where appropriate(^1), reaching 86 per cent in those with type 1 diabetes. Access to the diabetes team 7 day DISN provision

Table 6.1: Percentage of hospital sites with 7 day provision, England, 2015-19

| Percentage of hospital sites with: | 2015 | 2017 | 2019 | |-----------------------------------|------|------|------| | 7 day diabetes inpatient specialist nurse (DISN) provision | 7.0 | 9.5 | 17.1 | | 7 day Diabetes Physician access | – | 25.9 | 23.8 | | Both of the above | – | 4.8 | 8.3 |

Table 6.2: Percentage of inpatients seen by the diabetes team where it was deemed appropriate(^1): by 7 day DISN provision, England, 2019

| Percentage of patients: | 7 day DISN provision? | |-------------------------|-----------------------| | | Yes | No | | seen by the diabetes team where appropriate | 78.2 | * | 72.5 | \*

Findings

- Since 2015, 7 day DISN provision has more than **doubled**; an increase of 10 percentage points (from 7 to 17 per cent).
- However there has been a **decrease** in the proportion of hospital sites with 7 day Diabetes Physician access.
- A **higher** proportion of inpatients are seen by the diabetes team where appropriate when 7 day DISN cover is provided (78 per cent compared to 72 per cent).

Comment

Important aspects of DISN care are not captured in this metric. For example, weekend DISN teams provide reviews of those admitted during the week and identified to be at high risk of metabolic decompensation.

Notes: * = statistically significant at the 0.05 level ('Yes' vs. 'No' in audit year). n = not statistically significant ('Yes' vs. 'No' in audit year).

1. Based on the 'Think Glucose Criteria'. See Glossary: Referral to the diabetes team. Access to the diabetes team Diabetes team working and support systems

Table 6.3: Percentage of diabetes inpatient teams with an office which facilitates team working(^1), England, 2019

| Percentage of diabetes inpatient teams with: | 2019 | |---------------------------------------------|------| | • an office which facilitates team working | 74.0 |

Table 6.4: Percentage of hospital sites with diabetes inpatient management systems, England, 2019

| Percentage of hospital sites with: | 2019 | |-----------------------------------|------| | • an electronic system to identify and notify the inpatient diabetes team of all people with diabetes on admission | 35.9 | | • a system to help non-specialist staff identify and prioritise those with diabetes that need reviewing by the inpatient diabetes team | 63.0 |

Findings

- Almost **three-quarters** of diabetes inpatient teams have an office which facilitates team working (74 per cent).
- Take-up of automated systems to identify and notify the diabetes team to new diabetes admissions is low (**35.9 per cent**), probably reflecting the fact that only about 50 per cent of hospital sites have electronic medical records.
- Only **63.0 per cent** of hospital sites have systems to triage those needing a diabetes review.

Notes: 1. There is a shared working environment specifically for the team. 7. Key messages: Surgical care

Findings

- On the audit day in 2019, **4 out of 5** elective surgery inpatients had been prioritised in the surgical list (80 per cent).
- Only **2 out of 5** of the surgical inpatients audited in 2019 had their capillary blood glucose(^1) (CBG) levels recorded at all recommended stages of the perioperative pathway(^2) (43 per cent): At sign-in and sign-out stages of the surgical safety checklist, during surgery, in theatre recovery, on arrival on the ward.
- Emergency surgery inpatients were **less likely** to have their CBG levels recorded than elective surgery inpatients (41 vs 47 per cent).

**Recommendation 5:** All hospital trusts should have clear, audited perioperative pathways from pre-assessment through to discharge. These should be broadly in line with [NCEPOD](https://www.ncepod.org.uk/2018pd.html) recommendations.

Notes: 1. The concentration of glucose in the blood. 2. NCEPOD (2018) Perioperative Diabetes. Recommendation 4, p.12: [https://www.ncepod.org.uk/2018pd.html](https://www.ncepod.org.uk/2018pd.html). Surgical care: Diabetes management

Table 7.1: Proportion of hospital sites having perioperative diabetes care structures, England, 2019

| Care structure | Yes? | Per cent | |--------------------------------------------------------------------------------|------|----------| | Is there a team responsible for organising perioperative diabetes care? | | 30.9 | | Is there a standardised process for pre-operative diabetes care covering diabetes control, blood pressure and management of comorbidities? | | 61.3 | | Is there a referral pathway to ensure elective patients who need pre-admission optimisation of diabetes control are seen by an appropriate health care professional? | | 65.7 |

Chart 7.1: Nature of surgery, England, 2015-19

| Audit year | Elective | Emergency | |------------|----------|-----------| | 2015 | 41.4 | 58.6 | | 2017 | 41.6 | 58.4 | | 2019 | 40.2 | 59.8 |

Notes: * = statistically significant at the 0.05 level (vs. current audit year).

n = not statistically significant (vs. current audit year).

Findings

- Only 3 out of 10 hospital sites have a team responsible for organising perioperative diabetes care (31 per cent).
- There were 18 per cent fewer surgical inpatients in the 2019 audit compared to 2015 (2,035 vs 2,495), with drops in both elective (1,033 to 819) and emergency surgical inpatients (1,462 to 1,216). Surgical care: CBG recording and surgical prioritisation

Table 7.2: Proportion of surgical inpatients having their capillary blood glucose (CBG)(^1) levels recorded, England, 2019

| Are the CBG levels(^1) recorded in the following areas: | Elective | Emergency | Total | |----------------------------------------------------------|----------|-----------|-------| | At sign-in and sign-out stages of the surgical safety checklist(^2) | 66.3 n | 63.6 n | 64.4 | | In anaesthetic charts – during surgery(^3) | 62.2 * | 54.9 * | 57.5 | | In theatre recovery | 72.6 n | 68.9 n | 70.2 | | On arrival on the ward | 85.8 n | 85.6 n | 85.5 | | All of the above | 47.0 * | 40.6 * | 43.0 |

Table 7.3: Proportion of elective surgical inpatients prioritised to avoid prolonged starvation, England, 2019

| Care process | Yes? | |--------------|------| | For elective cases, was the patient prioritised to avoid prolonged starvation(^4)? | 80.2 |

Findings

- Only 4 out of 10 of the surgical inpatients audited in 2019 (43 per cent) had met the NCEPOD recommendation(^5) of having CBG levels recorded in all four clinical areas.
- Emergency surgery inpatients were less likely to have their CBG levels recorded.
- 4 out of 5 elective surgery inpatients had been prioritised in the surgical list (80 per cent).

Notes: * = statistically significant at the 0.05 level (vs. other admission type). n = not statistically significant (vs. other admission type).

1. The concentration of glucose in the blood. 2. e.g. WHO safety checklist. 3. If operation >1hr. 4. usually to the first third of the list. 5. NCEPOD (2018) Perioperative Diabetes. Recommendation 4, p.12: [https://www.ncepod.org.uk/2018pd.html](https://www.ncepod.org.uk/2018pd.html)
2. Key messages: Patient experience

Findings

- Inpatient perception of meal choice and timing dropped in 2015 and has not recovered.
- Inpatient perception of staff knowledge and ability to answer questions on diabetes has not changed compared to 2010.
- The proportion of inpatients who were satisfied with staff awareness of their diabetes has worsened since 2010.
- There has been no change in measures relating to inpatient empowerment: self-management, self-administration and involvement in care planning.

Clinical comment: Inpatients should be empowered to take control of their diabetes as much as possible, and patient expertise in their own diabetes care should be harnessed. However the NaDIA Patient Experience has found no increase in inpatient reported self-management, and the NaDIA Hospital Characteristics survey has found a large reduction in the percentage of hospital sites with a policy or guideline for self-management of diabetes.

Recommendation 6: All trusts should have and promote a self-management policy, which supports patients who want to self-manage their diabetes to safely do so while in hospital, as clinically appropriate and in line with wider NHS England and NHS Improvement policies on inpatient self-management. Findings

- Inpatient perception of meal choice and timing and staff awareness of their diabetes have **worsened** since 2010.
- There has been **no change** in measures relating to inpatient empowerment: self-management, self-administration and involvement in care planning.

### Table 8.1: Trends in inpatients’ views of their hospital stay, England, 2010-19

| Inpatients... | 2010 | 2013 | 2015 | 2017 | 2019 | Significant difference (p \<0.05) | |---------------|------|------|------|------|------|----------------------------------| | | | | | | | 2010 to 2019 | 2017 to 2019 | | Aware of diabetes team¹ | - | - | - | 51.8 | n | 53.5 | N/A | No change | | Inpatients satisfied with... | | | | | | | | | | Involvement in care planning¹ | - | - | - | 62.6 | n | 60.4 | N/A | No change | | Extent that ward staff respected wishes around diabetes care¹ | - | - | - | 91.1 | n | 91.5 | N/A | No change | | Control over blood sugar management¹ | - | - | - | 70.1 | n | 70.0 | N/A | No change | | Ability to self-administer insulin | 87.6 | n | 86.3 | 87.0 | 88.4 | n | 86.9 | No change | | Meal choice | 64.0 | * | 63.7 | 54.3 | 53.8 | n | 51.3 | Down ▼ | | Meal timing | 67.6 | * | 70.2 | 62.2 | 62.6 | n | 61.2 | Down ▼ | | Staff awareness of patient’s diabetes | 87.7 | * | 82.1 | 84.3 | 81.9 | n | 81.2 | Down ▼ | | Staff knowledge of diabetes | 64.7 | n | 67.5 | 65.5 | 64.6 | n | 63.7 | No change | | Staff ability to answer questions on diabetes | 88.4 | n | 86.2 | 87.5 | 85.9 | n | 86.3 | No change | | Overall care for diabetes | 83.7 | n | 86.1 | 84.3 | 83.4 | n | 82.1 | No change |

**Notes:** * = statistically significant at the 0.05 level (vs. current audit year), deft = 2. n = not statistically significant (vs. current audit year), deft = 2. ¹ Changes to the 2017 Patient Experience questionnaire means that historic results are not comparable. Findings

- The proportion of hospital sites with a policy or guideline for self-management of diabetes has **fallen** (from 63 per cent in 2015 to 46 per cent in 2019).
- **35 per cent** of hospital sites still do not have a policy or guideline for self-administration of diabetes medication. Glossary: NaDIA data collection

Data collection

Each participating hospital identified all inpatients with diabetes and distributed questionnaires accordingly. Where the patient was able and willing a Patient Experience (PE) form was completed, as well as a Bedside Audit (BA) form which provided information on the patient’s medical treatment taken from the patient’s notes. The hospital team also completed a Hospital Characteristics (HC) questionnaire providing information on the hospital’s resources and staffing structure.

Which patients are included in the audit? A patient was included in the inpatient audit (NaDIA) if they had been admitted to a hospital bed for 24 hours or more. Patients on an Obstetric or Paediatric ward were excluded from this audit. Mental Health wards were also excluded due to the high prevalence of long stay patients. Other exclusions included:

- Patients who were hyperglycaemic but not yet formally diagnosed with diabetes
- Accident and Emergency
- Day case ward
- Day surgery unit patients
- Observation ward (if patients had been admitted for less than 24 hours)
- Surgical short stay unit (if patients had been admitted for less than 24 hours)
- Palliative care centres
- Community hospitals Glossary: Diabetes type

**Diabetes** is a serious life-long health condition that causes a person's blood glucose (sugar) level to become too high. This occurs when there is not enough of the hormone insulin to manage blood glucose (BG) levels effectively. If untreated, diabetes leads to serious illness and death.

There are two main diabetes types:

- **Type 1 diabetes** develops when the insulin-producing cells in the body have been destroyed and the body is unable to produce any insulin.

  Type 1 diabetes accounts for about 10 per cent of all adults with diabetes (7 per cent of inpatients with diabetes) and is treated by daily insulin doses. Type 1 diabetes can develop at any age but usually appears before the age of 40, and especially in childhood.

- **Type 2 diabetes** develops when the insulin-producing cells in the body are unable to produce enough insulin, or when the insulin that is produced does not work properly (known as insulin resistance).

  Type 2 diabetes usually appears in people over the age of 40, though it may appear at any age. Type 2 diabetes accounts for around 90 per cent of adults with diabetes (around 93 per cent of inpatients with diabetes).

**Notes:**

1. Diabetes UK: [What is type 1 diabetes?](https://www.diabetes.org.uk/what-is-diabetes/type-1-diabetes)
2. Diabetes UK: [What is type 2 diabetes?](https://www.diabetes.org.uk/what-is-diabetes/type-2-diabetes) Glossary: Diabetes treatments

There are a number of treatments available to help manage and control diabetes. All patients are different, so treatment will vary depending on individual needs(^1).

- **Insulin**: Everyone with type 1 diabetes, and some people with type 2 diabetes, need to take insulin to control blood glucose (BG) levels(^1).

- **Tablets**: Some people with type 2 diabetes (and a minority with type 1 diabetes) use tablets to help control their BG levels(^1). Common tablet treatments include Biguanide (Metformin) and Sulphonylureas.

- **Lifestyle**: Type 2 diabetes can sometimes be controlled through healthy eating and increased exercise. However type 2 diabetes is a progressive condition, and over time people with type 2 diabetes may need medication (insulin or tablets) to help manage their BG levels.

For NaDIA analysis, inpatients with type 2 diabetes are grouped into three sub-categories based on their treatment type:

- **Type 2 (insulin)**
- **Type 2 (non insulin)**
- **Type 2 (diet only)**

Inpatients with type 1 diabetes are reported as a single group.

Notes: 1. Diabetes UK: [Diabetes treatments](#). Glossary: Healthcare providers

NaDIA data is collected and submitted by healthcare professionals that work on applicable hospital wards in England and Wales (Wales did not participate in 2019). For NaDIA Hospital Level Analysis, data is aggregated by NaDIA hospital site, which may be an NHS trust, Welsh Local Health Board (LHB), an individual hospital or a grouping of hospitals that have chosen to have their results aggregated together.

Commissioners decide what health services are needed and ensure that they are provided. Clinical Commissioning Groups (CCGs) in England and LHBs in Wales are responsible for commissioning healthcare services.

The National Institute for Health and Care Excellence (NICE) produces guidelines for the treatment of diabetes. All diabetes inpatient services should follow these guidelines, so that people with diabetes receive the best possible healthcare. Glossary: Healthcare professionals

A wide variety of healthcare professionals are involved in the care of inpatients with diabetes, including (but not restricted to) the following professions:

- **Diabetes consultants** are senior hospital physicians who diagnose and treat patients with diabetes. Diabetes consultants are specialists in diabetology and endocrinology (the specialism concerning the glands and hormones).

- **Diabetes specialist nurses** (DSN) work to meet the needs of people with diabetes and provide experience and expertise as part of dedicated diabetes teams. DSNs work wholly in diabetes care. A **diabetes specialist inpatient nurse** (DISN) provides hospital inpatient care(^1).

- A **dietitian** is a healthcare professional with expertise in diet and nutrition. A **specialist diabetes dietitian** advises people with diabetes on the most suitable diet to control and manage their diabetes.

- **Podiatrists** are healthcare professionals that specialise in conditions of the feet and lower limbs. This includes the prevention, management and treatment of foot complications commonly experienced by people with diabetes (e.g. diabetic foot disease).

- **Diabetes specialist pharmacists** are healthcare professionals that specialise in the safe and effective management of medication for controlling and treating diabetes.

Notes: 1. Diabetes UK (2014) Position Statement: [Diabetes Specialist Nurses: Improving Patient Outcomes and Reducing Costs](https://www.diabetes.org.uk), 2014 Glossary: Healthcare teams

“Specialists involved in the delivery of diabetes care must work in multi-disciplinary foot care teams (MDFTs) for care to be truly effective. They should have received extensive training accredited at a national level.”

Healthcare professionals form multi-disciplinary specialist teams in hospitals to co-ordinate diabetes care, including (but not restricted to):

- Inpatient specialist **diabetes teams** or **MDiTs** co-ordinate diabetes care in hospitals. Diabetes teams usually consist of diabetes consultants, diabetes specialist (inpatient) nurses (DSN/DISN), podiatrists and dietitians, who will also work with other specialists who might also form part of the team (e.g. pharmacists and clinical psychologists).

- Inpatient **MDFTs** co-ordinate diabetes foot care in hospitals. MDFTs meet weekly and consist of a diabetes consultant (diabetologist), a podiatrist with skills in managing the diabetic foot and a surgeon (general, orthopaedic or vascular surgeon). MDFTs will also work with other specialists who might be incorporated into the team (e.g. DSN/DISNs, podiatrists, interventional radiologists, microbiologists, tissue viability nurses). 82 per cent of hospital sites have MDFTs.

- 65 per cent of hospital sites host regular diabetes **mortality and morbidity (M&M) meetings** for healthcare professionals to discuss patient deaths and adverse incidents relating to diabetes. At M&M meetings staff can discuss incidents in detail, report problems and share lessons to prevent the recurrence of adverse incidents.

Notes: 1. Diabetes UK (2010): Commissioning specialist diabetes service for adults with diabetes Glossary: Referral to the diabetes team

When should the patient be referred to the diabetes team?

- Patient request
- Sepsis
- Vomiting
- Foot ulceration
- Unable to self-manage
- Impaired consciousness
- Newly diagnosed type 1 diabetes
- Newly diagnosed type 2 diabetes
- Parenteral or enteral nutrition
- Severe hypoglycaemia
- Recurrent hyperglycaemia
- Acute coronary syndrome
- Previous problems with diabetes as inpatient
- Intravenous insulin infusion for over 48 hours
- Intravenous insulin infusion with glucose outside limits
- Diabetic ketoacidosis (DKA)
- Hyperosmolar hyperglycaemic state (HHS)
- Admission for urgent or major elective surgical procedure
- End of life care

Derived from the ‘Think Glucose Criteria’ developed by the NHS Institute for Innovation Think Glucose

Notes: 1. Think Glucose Executive Leaders’ Guide - NHS England: https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/Think-Glucose-Executive-Leaders-Guide.pdf Glossary: Healthcare technologies

Hospitals may use some or all of the following healthcare technologies which support inpatient care:

- **An electronic patient record (EPR)** is a computer system designed to collect and store patients' clinical and health information in one place, replacing paper-based health records and multi-platform data collection. Hospital staff involved in patient care can access and update the EPR system at different points in the patient's care. A variety of EPR systems are used. More than one third of hospital sites fully-utilise an EPR system (37 per cent).

- **Hospital electronic prescribing (EP)** is a computer system designed to allow prescriptions to be sent to pharmacies through IT systems, rather than through paper prescriptions. More than 4 out of 10 hospital sites fully-utilise an EP system (45 per cent).

- **Remote blood glucose monitoring (BGM)** tools allow remote access to the measurement of patient blood glucose (BG) levels. Results can be transmitted to patients and caregivers in real time, providing an early warning if BG levels are outside the expected levels. More than 7 out of 10 hospital sites fully-utilise remote BGM (71 per cent). People with diabetes are at much greater risk of developing problems with their feet (diabetic foot disease), due to the damage raised blood sugars can cause to sensation (neuropathy) and circulation (ischaemia). If left untreated, these problems can cause foot lesions (ulcers) and infections and, at worst, may lead to amputations(^1).

About 9 per cent of inpatients with diabetes are admitted to hospital with active diabetic foot disease, around half of which are admitted for diabetic foot disease.

On admission to hospital, inpatients with diabetes may undergo a specific diabetic foot risk examination for ulceration, in addition to general pressure sore checks such as the Waterlow score.

Hospitals may follow foot care examination initiatives such as ‘Putting Feet First’(^2) or NICE inpatient foot guidance(^3) and may also have tools or systems in place to increase the number of inpatients with diabetes that have a specific diabetic foot risk examination.

Inpatients with active diabetic foot disease or at a high risk of developing foot problems should be assessed by the multi-disciplinary foot care team (MDFT – see Glossary: Healthcare Teams) as soon as possible following admission. 82 per cent of hospital sites have MDFTs.

If inpatient foot care is not effective, hospital-acquired diabetic foot lesions can arise. Foot lesions are associated with great patient distress, risk of amputation, increased mortality and high cost. **Whilst under a hospital’s care, no patient should deteriorate enough so that they develop a new instance of a foot lesion.**

Notes: 1. Diabetes UK: [Diabetes and foot problems](https://www.diabetes.org.uk/healthcare-professionals/diabetes-and-foot-problems) 2. Diabetes UK: [Putting Feet First](https://www.diabetes.org.uk/healthcare-professionals/putting-feet-first) 3. NICE: NG19: [Diabetic foot problems: prevention and management](https://www.nice.org.uk/guidance/ng19) Glossary: Medication errors

Hospital inpatients have **drug charts** to record their prescribed medication. Some entries contain **medication errors**, which have the potential to cause or contribute towards patient harms (see **Glossary: Patient harms**). Medication errors can be categorised by incident type (**prescription** or **glucose management**) and medication type (**insulin** or **OA-DA**). A summary is shown in the table below:

| Error description | Error type | |-------------------|------------| | Insulin not written up | Insulin prescription error | | Name of insulin incorrect | Insulin error | | Number (dose) unclear | Prescription error | | Unit abbreviated to ‘u’ or written unclearly | Medication error | | Insulin or prescription chart not signed by prescriber | | | Insulin not signed as given | | | Insulin given/prescribed at the wrong time | | | OA-DA not signed as given | OA-DA prescription error | | OA-DA given/prescribed at the wrong time | OA-DA error | | Wrong dose | | | OA-DA not written up | | | Insulin not increased when persistent BG >11 mmol/L and better glycaemic control appropriate for this patient | Insulin management error | | Insulin not reduced if unexplained BG \<4 mmol/L | Insulin error | | Inappropriate omission of insulin after episode of hypoglycaemia | Glucose management error | | No action taken when persistent BG >11 mmol/L and better glycaemic control appropriate | | | OA-DA not reduced if unexplained BG \<4 mmol/L | OA-DA management error | | Inappropriate omission of OA-DA after episode of hypoglycaemia | OA-DA error |

**Notes:** 1. OA-DA = Oral anti-diabetic agents are drugs used for the treatment of people with type 2 diabetes. BG = blood glucose. Glossary: Patient harms

There are a variety of patient harms that people with diabetes may develop in hospital. These potentially life-threatening events are entirely preventable and strenuous efforts must be taken to avoid them.

A hypoglycaemic episode (a hypo) is a potentially dangerous drop in a patient’s blood glucose (BG) to below 4.0 mmol/L. ‘Normal’ BG (normoglycemia) is typically between 4.0 and 8.0 mmol/L.

- A ‘mild’ hypoglycaemic episode involves a BG level of between 3.0 and 3.9 mmol/L.
- A ‘severe’ hypoglycaemic episode involves a BG level of less than 3.0 mmol/L.

A hypoglycaemic episode requiring injectable rescue treatment occurs in severe cases of hypoglycaemia when the patient is unconscious and cannot take sugar by mouth. Rescue treatment is applied using an injection of glucose or Glucagon.

A patient whose BG levels are properly managed should never experience a severe hypoglycaemic episode or require rescue treatment during their hospital stay.

Diabetic ketoacidosis (DKA) mainly occurs in people with type 1 diabetes when a severe lack of insulin means the body cannot use glucose for energy and the body starts to break down other body tissue, releasing ketones as an alternative energy source. This can lead to ketoacidosis if the levels are too high. The development of DKA after admission suggests that the inpatient’s insulin treatment was omitted, or insufficient levels of insulin were provided, for an appreciable time. DKA is a potentially life-threatening emergency which should not develop in hospital.

Hyperosmolar hyperglycaemic state (HHS) mainly occurs in people with type 2 diabetes who experience very high BG levels (often over 40mmol/L). It can develop over a course of weeks through a combination of illness (e.g. infection) and dehydration. HHS is a potentially life-threatening emergency which should not develop in hospital.

Patients with diabetes are at a higher risk of developing foot lesions (ulcers) because of associated blood flow (ischaemia) and nerve problems (neuropathy). No patient should deteriorate enough while under a hospital’s care that they develop a new foot lesion. **Glossary: NaDIA-Harms**

**NaDIA-Harms** is a continuous audit of inpatient harms that runs parallel to the annual NaDIA snapshot covered in this report.

**Why is NaDIA-Harms necessary?:** The snapshot nature of the annual NaDIA collection, coupled with the relatively low incidence of the four inpatient harms, means that continuous collection via NaDIA-Harms is needed to allow robust monitoring at **local level**, and contribute to the drive to lower the incidence of these serious inpatient harms.

In time, the NaDIA-Harms audit will enable NHS trusts to identify and analyse local occurrences of these key inpatient harms, supporting local **quality improvement** (QI) work. By collecting patient identifiers in NaDIA-Harms, the audit can harness the power of the core National Diabetes Audit (NDA) via **data linkage**, allowing case-mix adjusted **benchmarking** to be reported and **risk-adjusted** long term outcomes identified. Additionally, national characterisation of which patients are at **highest risk** will inform the development of better preventive care.

**Comparability:** In the latest **NaDIA-Harms report**, the NaDIA snapshot figures in slides **14, 15 and 16** have been used to produce an estimate of NaDIA-Harms case ascertainment, which ranges from 20 per cent (DKA) to just 6 to 8 per cent (others). Given these relatively low completeness levels, it is envisaged that the NaDIA snapshot will continue to collect data on inpatient harms over the next few years as participation in NaDIA-Harms improves.

The latest NaDIA-Harms report covering May 2018 to October 2019 is here: [http://digital.nhs.uk/pubs/nadia-harms2019](http://digital.nhs.uk/pubs/nadia-harms2019). To find out whether the **patient experience** was favourable, the audit collects patient feedback on the following measures:

| NaDIA Measure | Rationale | |----------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------| | • Involvement in care planning | Inpatients should be empowered to become involved in their care planning as much as possible. Patient expertise in their diabetes care should be harnessed. | | • Extent that preferences for diabetes treatment taken into account | Patient preferences for their diabetes treatment should be accommodated where possible. | | • Ability to take control of their diabetes | Inpatients should be empowered to take control of their diabetes as much as possible. Patient expertise in their diabetes care should be harnessed. | | • Ability to self-administer insulin | | | • Meal choice | The timely provision of suitable food is integral to good diabetes management. | | • Meal timing | | | • Staff awareness of diabetes | Staff need to know which patients have diabetes to ensure the appropriate treatment is given. | | • Staff knowledge of diabetes | Staff expertise in diabetes is essential to ensure the appropriate treatment is given and patient questions can be addressed. | | • Staff ability to answer questions on diabetes | Patients overall perception of their diabetes care during their hospital stay is a useful measure of the patient experience as a whole. | | • Overall care for diabetes | | Glossary: Acronyms

BA form = NaDIA Bedside Audit form BG = blood glucose CCG = Clinical Commissioning Group DISN = diabetes inpatient specialist nurse DKA = diabetic ketoacidosis DSN = diabetes specialist nurse EP = electronic prescribing EPR = electronic patient records HC form = NaDIA Hospital Characteristics form HHS = hyperosmolar hyperglycaemic state HQIP = The Healthcare Quality Improvement Partnership IVII = intravenous insulin infusion JBDS-IP = Joint British Diabetes Societies for Inpatient Care group LHB = Welsh Local Health Board M&M meeting = mortality and morbidity meeting MDFT = multi-disciplinary foot care team

mmol/L = millimole (one thousandth of a mole) per litre NaDIA = National Diabetes Inpatient Audit NCAPOP = National Clinical Audit Patient Outcomes Programme NCVIN = National Cardiovascular Intelligence Network NDA = National Diabetes Audit NICE = National Institute for Health and Care Excellence OA-DA = Oral anti-diabetic agent PE form = NaDIA Patient Experience form QOF = Quality and Outcomes Framework Additional information: Summary

The following documents are available from http://digital.nhs.uk/pubs/nadia2019

• A one page executive summary of this report. • A PowerPoint version of this report. • Deep-dive reports on individual chapters, including report chapters as standalone publications (pdf and PowerPoint). • Hospital site level 2010-2019 charts and data • Supporting data in Excel format • Data Quality Statement • Methodology Additional information: References

Diabetes UK (2010): Commissioning specialist diabetes service for adults with diabetes: https://www.diabetes.org.uk/resources-s3/2017-09/defining%2520specialist%2520diabetes%2520service%2520for%2520adults%2520with%2520diabetes.doc

Diabetes UK: Diabetes and foot problems: https://www.diabetes.org.uk/Guide-to-diabetes/Complications/Feet/

Diabetes UK: Diabetes treatments: https://www.diabetes.org.uk/Diabetes-the-basics/Diabetes-treatments/

Diabetes UK (2018): Making hospitals safe for people with diabetes: https://www.diabetes.org.uk/resources-s3/2018-10/Making Hospitals safe for people with diabetes_FINAL.pdf

Diabetes UK (2014) Position statement: Diabetes Specialist Nurses: Improving Patient Outcomes and Reducing Costs: https://www.diabetes.org.uk/Documents/Position statements/Diabetes-Specialist-Nurses_Improving-patient-outcomes-and-reducing-costs-position-statement-February2014.pdf

Diabetes UK: Putting Feet First: https://www.diabetes.org.uk/putting-feet-first

Diabetes UK: Testing: https://www.diabetes.org.uk/Guide-to-diabetes/Managing-your-diabetes/Testing/

Diabetes UK: What is type 1 diabetes?: https://www.diabetes.org.uk/Diabetes-the-basics/What-is-Type-1-diabetes/

Diabetes UK: What is type 2 diabetes?: https://www.diabetes.org.uk/Diabetes-the-basics/What-is-Type-2-Diabetes/

EU General Data Protection Regulation. Article 6: Lawfulness of processing: https://www.privacy-regulation.eu/en/article-6-lawfulness-of-processing-GDPR.htm

Getting It Right First Time (GIRFT): Diabetes. Forthcoming publication TBC.

Joint British Diabetes Societies for Inpatient Care (2014): The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients: http://www.diabetologists-abcd.org.uk/JBDS/JBDS_IP_VRIII.pdf

Lexico: Perioperative: https://www.lexico.com/definition/perioperative

NCEPOD (2018): Perioperative Diabetes: https://www.ncepod.org.uk/2018pd.html

NICE: Diabetic foot problems: Prevention and management: https://www.nice.org.uk/Guidance/NG19

NICE: Diabetes in adults: https://www.nice.org.uk/Guidance/QS6

NHS England: Diabetes transformation fund: https://www.england.nhs.uk/diabetes/diabetes-prevention/diabetes-transformation-fund/

NHS England (2019): NHS Long Term Plan: https://www.longtermplan.nhs.uk/

NHS England: Serious Incidents Framework: https://www.england.nhs.uk/patientsafety/serious-incident/ The NaDIA team would like to thank all the people and teams who have worked hard to contribute to this unique and valuable insight into the inpatient care of people with diabetes.

Development and delivery of the NaDIA is guided by a multi-professional advisory group of clinicians and patient representatives, chaired by Gerry Rayman. The NaDIA Advisory Group members include:

Gerry Rayman Consultant Diabetologist and National Clinical Lead for Inpatient Diabetes (Chair) Bob Young NDA Specialist Clinical Lead Neera Agarwal Diabetes & Endocrinology Training Programme Director (Wales Deanery) Deputy Programme Director Belinda Allan Consultant Diabetologist, Michael White Centre for Diabetes and Endocrinology (Hull) Alex Berry Engagement Lead, Diabetes UK Olivia Burr Inpatient Care Lead, Diabetes UK Anne Claydon Nurse Consultant for Diabetes, Barts Health NHS trust Sophie Colling NDA Project Support Officer, Diabetes UK Ketan Dhatriya Consultant Diabetologist, Norfolk and Norwich University Hospitals NHS Foundation Trust Anne Kilvert Consultant Diabetologist, Northampton General Hospital NHS trust Alistair Lumb Consultant in Diabetes and Acute General Medicine, Oxford University Hospitals NHS Foundation Trust Michael Mason Information Analyst, NHS Digital Maureen McGinn Patient representative Julie Michalowski Audit Manager, NHS Digital Omar Mustafa Consultant Diabetologist, Kings College Hospital Rustam Rea Consultant in Diabetes and Acute General Medicine, Oxford University Hospitals NHS Foundation Trust Aled Roberts Consultant Diabetologist - Wales David Roberts Patient Representative Debbie Stanisstreet Lead Nurse for Diabetes and Endocrinology (Lister Hospital) & Diabetes Inpatient Specialist Nurse Network Garry Tan Consultant Diabetologist, Oxford Centre for Diabetes, Endocrinology and Metabolism Andrew Whitehead Audit Coordinator, NHS Digital Emily Watts Inpatient Care Lead, Diabetes UK Emilia Woch Higher Information Analyst, NHS Digital Arthur Yelland Senior Information Analyst, NHS Digital The Healthcare Quality Improvement Partnership (HQIP). The National Diabetes Inpatient Audit (NaDIA) audit is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). HQIP is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing, and National Voices. Its aim is to promote quality improvement in patient outcomes, and in particular, to increase the impact that clinical audit, outcome review programmes and registries have on healthcare quality in England and Wales. HQIP holds the contract to commission, manage, and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP), comprising around 40 projects covering care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS England, the Welsh Government and, with some individual projects, other devolved administrations and crown dependencies [www.hqip.org.uk/national-programmes](http://www.hqip.org.uk/national-programmes).

NHS Digital is the new name for the Health and Social Care Information Centre. NHS Digital managed the publication of the 2020 annual report.

Diabetes UK is the largest organisation in the UK working for people with diabetes, funding research, campaigning and helping people live with the condition.

The National Cardiovascular Intelligence Network (NCVIN) is a partnership of leading national cardiovascular organisations which analyses information and data and turns it into meaningful timely health intelligence for commissioners, policy makers, clinicians and health professionals to improve services and outcomes.